LOMO 3-2014.indd

Nutr Hosp. 2014;29(3):563-567
ISSN 0212-1611 • CODEN NUHOEQ
S.V.R. 318
Original / Nutrición enteral
Enteral nutrition in critical patients; should the administration be
continuous or intermittent?
Viviane Maeve Tavares de Araujo1, Paulo César Gomes2 y Cervantes Caporossi3
1
Nutritionist at the Julio Muller University Hospital. Federal University of the State of Mato Grosso. Brazil (UFMT-BR). 2Coursing Master in Health Sciences at the Health Sciences Post-Graduation Program. Medical Sciences School (FCM)-UFMT-BR.
3
Adjunct Professor at the Clinical Surgery Department of FCM/UFMT-BR. Brazil.
Abstract
Enteral nutrition therapy (ENT) is an essential part
in the management of critically ill patients, having a
significant impact on these patients’ clinical results. It
can be administered on a continuous or intermittent
basis using an infusion pump. There is a discussion on
which of these techniques has the best performance,
involving a number of factors such as nausea, diarrhea,
and particularly the relationship between diet volume
and the ratio of programed calories to calories effectively
supplied to the critical patients.
Objectives: To compare the forms of continuous or
intermittent infusion of enteral nutrition, using as primary
outcome the level of estimated caloric needs daily supplied.
Methods: Observational prospective randomized clinical
study carried out in an intensive care unit on 41 patients
divided into two groups, of intermittent (ENT during
18 hours with a 6-hour nocturnal pause), or continuous
(ENT during 24 hours continuously) administration. The
secondary outcome variables measured in this study were
bowel evacuation, distension, emesis, with the primary
outcome variable being the relationship between infusion
volume and the estimated-to-supplied ratio of caloric
needs. The rejection index of the null hypothesis was
established at 5% for all the tests.
Results: Most of the patients received more than 60%
infusion of enteral diet over the 5 days of study (p = 1.0),
with no difference regarding the provision of caloric
needs. No statistically significant difference between
groups was found in the variables vomiting, abdominal
distension or diarrhea.
Conclusion: The administration modalities of continuous
or intermittent enteral nutrition are similar in which
regards the comparison of the variables included in this
study.
(Nutr Hosp. 2014;29:563-567)
DOI:10.3305/NH.2014.29.3.7169
Keywords: Enteral nutrition. Intermittent and continuous
administration.
Correspondence: Viviane Maeve Tavares de Araujo.
Hospital Universitario Julio Muller.
Rua João Carlos Pereira Leite, 526.
78005570 Cuiaba. Brazil.
E-mail: [email protected]
Recibido: 12-II-2013.
1.ª Revisión: 25-XI-2013.
Aceptado: 1-XII-2013.
NUTRICIÓN ENTERAL EN PACIENTES CRÍTICOS;
¿SU ADMINISTRACIÓN DEBERÍA SER CONTINUA
O INTERMITENTE?
Resumen
La terapia con nutrición enteral (TNE), una parte
esencial del manejo de los pacientes críticos, tiene un impacto significativo en los resultados clínicos de estos pacientes. La TNE puede administrarse de forma continua
o intermitente utilizando una bomba de infusión. Existe
una discusión sobre cuál de estas dos técnicas tiene un
mejor rendimiento, lo que implica una serie de factores
como náuseas, diarrea y especialmente la relación entre
el volumen de la dieta y la proporción entre calorías que
se programan y las que realmente se proporcionan efectivamente a los pacientes críticos.
Objetivos: Comparar las formas continua e intermitente de infusión de nutrición enteral, utilizando un nivel
de necesidades calóricas estimadas suministradas diariamente como resultado principal.
Métodos: Estudio clínico prospectivo y observacional,
de distribución aleatoria, de 41 pacientes en una unidad
de cuidados intensivos (UCI), divididos en dos grupos,
intermitente (TNE durante 18 horas con una pausa nocturna de 6 horas) o continua (TNE durante 24 horas de
forma continua). Evaluamos como variables secundarias
de resultados la evacuación, distención, emesis y como
variable principal de resultado la relación entre el volumen de infusión y el cociente entre necesidades calóricas
estimadas a suministradas. Se estableció el índice de rechazo de la hipótesis nula en el 5% para todos los tests.
Resultados: La mayoría de los pacientes recibieron >
60% de la infusión de la dieta enteral a lo largo de los 5
días del estudio (p = 1,0), sin observarse diferencias en
la provisión de las necesidades calóricas. No se observaron diferencias estadísticamente significativas entre los
grupos con respecto a las variables vómitos, distensión
abdominal o diarrea.
Conclusión: Las modalidades intermitente o continua
de administración de la nutrición enteral son similares
en lo que respecta a la comparación de las variables de
este estudio.
(Nutr Hosp. 2014;29:563-567)
DOI:10.3305/NH.2014.29.3.7169
Palabras clave: Nutrición enteral. Administración continua
e intermitente.
563
Introduction
Nutrition therapy is essential among the health care
practices for critically ill patients. It is an adjuvant
therapy which main objective is to attenuate the development of malnourishment.1 Its efficiency depends
on a number of factors, such as metabolic status of the
patient and his/her response and behavior during the
treatment.
Enteral nutrition therapy (ENT) has presented good
results for a critically ill patient, therefore this is generally preferred to a total parenteral nutrition whenever
the patient’s gastrointestinal tract allows for it.2 The use
of enteral nutritional support is linked to reduced infective complications, maintenance of intestinal mucosal
barrier integrity, and reduced bacterial translocation.1
However, the clinical behavior of this group of patients may interfere with ENT, thus affecting its administration and, as a consequence, its efficiency. This
clinical characteristic may be directly linked to severity of the disease or to its treatment, with the requirement for sedatives, mechanical ventilation and therapy
with antibiotics or vasoactive drugs.
The clinical manifestations of these alterations generally occur through the presence of intercurrent disorders such as abdominal distension, vomiting, and
diarrhea.3,4 Pulmonary infection caused by bronchial
aspiration due to the increased volume of gastric residue between feeding steps, which has high morbidity and mortality, is one of the most feared complications.5,6 Such complications may interfere with one
of the basic concepts of the objective of this therapy,
which is to supply calories to the patient; additionally,
they may determine a decrease in the total caloric infusion goal prescribed to the patient.
Therefore, the modality of ENT infusion, either
continuous or intermittent, may influence such complications.
However, few studies can be found in the literature
with conclusive results on this subject, mainly in critical patients. The purpose of this study is to compare
two methods of ENT infusion (continuous or intermittent), and the way in which they can contribute toward
complications which impair the efficacy of the therapy.
On admission to the ICU, patients were randomly
assorted to Group I-intermittent (ENT for 18 hours,
with one 6-hour nocturnal pause), or Group II-continuous (ENT for 24 hours uninterruptedly). In both
groups enteral nutrition therapy was delivered through
an infusion pump.
In addition, on admission to the ICU patients had
their nutritional status assessed using the Global Subjective Evaluation-GSE; severity of their condition and
metabolic stress was assessed using APACHE II (acute
physiology and chronic health evaluation) score (< 10
indicates mild disease). Caloric and protein needs were
estimated by the following rules: a) 25-30 calories/kg
of body weight, and b) 1.5 g of protein/kg of body
weight. The estimated caloric needs were gradually
delivered during the first three days of hospital stay
(30%, 60% and 100%, respectively). A commercially
available processed enteral formula (Peptamen®), nutritionally complete, was used for both groups, containing 100% whey protein, with 1.5 cal/ml caloric
density.
Patients underwent bedside gastric residue volume
assessment by manual aspiration performed before installation of any new step of enteral diet. The cutpoint
level of 250 ml was established to continue or suspend
ENT administration, which is in agreement with the
protocol followed in our medical service.
The level of caloric needs was determined by observing the quantity of ENT infusion collected by the
nursery report and annotations made on the fluid balance
form, continuously monitored during 24 hours. Inherent complications due to the use of ENT were also
monitored, with the following study variables being
chosen: incidence of diarrhea, bowel constipation, distension and vomit.
Sample calculation was based on the variable gastric residue; considering an 80% beta error (type II)
the sufficient number of patients was calculated to be
16. The Chi-square and Fisher’s Exact tests were used
to compare categorical data and to test the association
between independent variables. Student’s t or Mann
Whitney’s tests were used to compared two continuous
variables. Comparison between variables was made
using Relative Risk (RR) with a 95% Confidence Interval. The rejection index of the null hypothesis was
established at 0.05 or 5% (α = 5%).
Methods
Observational, prospective, randomized clinical
study, carried out on patients under clinical treatment,
over 18 years of age, of both genders, candidates to
receive enteral nutrition therapy exclusively. The nasoenteral feeding tube was placed in gastric location
and data were collected during the first five days in
hospital. Patients with diabetes, hypothyroidism or any
surgery in the upper gastrointestinal tract were excluded.
The project was approved by the Research Ethical
Committee of Julio Muller University Hospital (CEP
637/09).
564
Nutr Hosp. 2014;29(3):563-567
Results
After randomization 41 patients were included in
the study, 18 (44%) in Group I (intermittent) and 23
(56%) in Group II (continuous).
Demographics and clinical data are displayed in table I, where no difference between the groups could
be identified.
The percentage of nutritional intake received along
the study days was described. During the five study
days it could be noticed that 17 patients (74%) in
Viviane Maeve Tavares de Araujo et al.
Table I
Demographics and clinical data of the study sample
G1 (18 h)
Variable
G2 (24 h)
Mean
SD
Mean
SD
p
Estimated weight (kg)
70.2
± 15.2
60.5
± 14.7
0.08*
Height (cm)
1.7
± 0.2
1.6
± 0.1
0.66*
Age (years)
68.9
± 19.4
61.3
± 20.8
0.23*
BMI (kg/m²)
24.6
± 5.0
22.3
± 4.3
0.13*
Gender (M/F)
Male
Female
10
08
14
09
01 (06)
11 (61)
06 (33)
03 (13)
11 (48)
09 (39)
0.76**
ASG (n%)
A
B
C
0.59***
Apache
20.7
4.95
22.4
6.05
0.33****
*Student t – Data as mean + SD.
**Fisher’s Exact Test.
***Chi-square Test.
****Mann Witney’s Test.
ASG Avaliação Subjetiva Global.
Table II
Achievement of caloric needs along the study days
Day when CN*
was achieved
G1 (18 h)
G2 (24 h)
Freq
%
% Acum
Freq
%
% Acum
p**
Did not achieve
Day in-hospital
First day
Second day
Third day
Fourth day
Fifth day
08
02
44
0
06
22
17
0
11
–
0
06
28
44
44
56
06
01
01
07
06
01
01
26
04
04
30
26
04
04
–
04
09
39
65
70
74
–
1.00
1.00
0,52
0.22
0.12
0.32
Overall total
18
100
–
23
100
–
–
01
04
03
*CN: Caloric needs.
**Fisher’s Exact Test.
Group II, but only 10 patients (56%) in Group I received adequate caloric intake. Although the needs in
Group II were achieved more quickly and in a higher percentage, no statistically significant difference
could be found in this study (p = 0.32), as shown in
table II.
Complementing table II, figure 1 demonstrates the
gradual increase of ENT acceptance as length of hospital stay advanced.
The study patients were evaluated according to the
complications they showed along the days of data collection. Table III displays the results obtained after exploring the variables bowel evacuation, distension, and
emesis. Both groups were similar in this regard, with
no statistically significant difference (p < 0.05 for the
three items above described).
Enteral nutrition in critical patients
At the end of data collection only 3 (7%) patients
died, and 38 (93%) patients who remained in the study
until the fifth day were considered as being discharged
from the project. There was no significant difference
between the two groups (p = 0.57).
Discussion
A mandatory discussion when using ENT relates to
what administration method is chosen, whether intermittent or continuous.
A global analysis of our data demonstrated that both
study groups had similar results, with no significant
differences relating to the method of ENT administration to the critical patients.
Nutr Hosp. 2014;29(3):563-567
565
80%
70%
60%
50%
40%
G1 (18 h)
G2 (24 h)
30%
20%
10%
0%
Day of
hospitalization
First
day
Second
day
Third
day
Fourth
day
Table III
Results of bowel evacuation, distension and
emesis assessments
Evacuation
G1 (18 h)
G2 (24 h)
p
Normal
Diarrhea
Constipated
10 (56%)
05 (28%)
03 (17%)
10 (44%)
06 (26%)
07 (30%)
0.57*
Distension
No
Yes
06 (33%)
12 (67%)
09 (39%)
14 (61%)
0.70*
Emesis
No
Yes
14 (78%)
04 (22%)
16 (70%)
07 (30%)
0.72**
*Chi-square Test.
**Fisher’s Exact Test.
Intermittent infusion resembles more the usual,
regular feeding process, which follows the physiological cycles. Interruption of the administration is programmed, thus allowing for a temporary rest from the
nutrition therapy of the patient.
Continuous infusion has the typical feature of providing a constant and slow flow, as required by patients
who do not tolerate any type of more rapid or voluminous infusion.5
In this study we consider that the regularity of infusion was maintained in both forms of administration
by programming the pump drip, the only difference
laying in the planned drip interruption in the intermittent form.
After determining the amount of caloric needs, we
observed during the five days of the study that neither
group achieved the supply of total estimated caloric
needs, according to table II.
Patients in Group II achieved the prescribed caloric
needs more rapidly, especially during the first 48 to 72
566
Nutr Hosp. 2014;29(3):563-567
Fifth
day
Fig. 1.—Days of hospitalization to achieve the caloric
needs.
hours. This difference was maintained until the fifth
day, yet no statistically significant difference was seen
in the comparison with Group I. A study showing results similar to ours found that a high percentage of
critical patients received less than 50% of the initially
prescribed caloric needs during the first days of ENT.6
A study conducted at the Julio Muller University
Hospital of UFMT involving critical patients in the
intensive care unit showed that 75.6% of patients using ENT took up to six days to fulfill their nutritional
needs.7 Their data are similar to the ones in this study.
It is worth noticing that an early achievement of the
programmed target of nutritional needs in fact interferes positively with the critical patient’s treatment.
Both methods presented advantages and disadvantages, since the differences they showed may interfere
with several physiological processes, consequently
with clinical processes as well.
As an example of such advantages, Vanessa Fujino
et al.8 suggest, in a revision of the literature, that a nocturnal interruption of six hours should be programmed
aiming to reduce the intragastric bacterial population.
During the nocturnal pause the gastric pH that was not
blocked by the diet falls down to a bactericidal level in the stomach, thus decreasing the gastrointestinal
tract bacterial population. This in turn will favor the
decrease in levels of nosocomial pneumonia due to
bacterial increase.
The variables we chose to represent complications
of using ENT in the study patients are often commented in studies about this subject.3,4,9 One of the most
discussed complications in this setting is the presence
of diarrhea, which often may become a factor to determine suspension of ENT in critical patients.
In a prospective study comparing the continuous
and intermittent methods of infusion, a higher incidence of diarrhea, tube displacement and aspiration
pneumonia was evidenced by the intermittent method
Viviane Maeve Tavares de Araujo et al.
of administration without the use of infusion pump. In
the group receiving continuous ENT there was greater
occurrence of pump obstruction, however they had as
advantage a higher percentage of infusion of the daily
prescribed diet.9
Ciocon et al.10 showed results where diarrhea was
significantly more frequent in the intermittent than in
the continuous group.
In our study the variables diarrhea and constipation
were equally frequent in both groups. After analyzing
the variables, no statistically significant difference was
found, thus asserting the groups parity.
Decrease in the incidence of this complication in the
ICU is considered a positive aspect, in addition to the
fact that in both surveys it was not a cause for interruption of ENT administration.3,9-11 It may be associated
to medications or infections rather than ENT. Additionally, diarrhea may adversely affect absorption of
nutrients and the nutritional status itself. These factors
lead to additional stress for the patient and to increased
healthcare costs.3,12
Whenever the patient presents with diarrhea, ENT
administration modality in critical patients is also a
very important point, which should be analyzed along
with the type of formula employed. Evidence exists
that the continuous use through infusion pump is a
strong ally in the treatment of diarrhea, since a decrease to small doses of the volume infused may enhance the patient’s tolerance to the enteral formula.5,9
In relation to the variable constipation, although the
comparison of the groups yielded no significant difference in our results, there is still controversy in the
literature on constipation in critical patients, so that no
specific definitions are available on this matter. Some
studies suggest that there is an association between
the critical status of a patient, who usually takes many
drugs, and the incidence of bowel constipation.12-14
The variables abdominal distension and emesis
were evaluated as well, however results were equipoise between the two groups, showing no statistically
significant difference.
Even if we consider the difficulties of collecting
data in critical patients, some remarks must be made to
our study. The reduced number of study days made it
impossible to evaluate the patients over longer periods,
which might likely yield different results.
Based on the present results, besides a mere adoption of ENT administration protocols for critical patients, we believe we can give a contribution to the
clinical practices followed nowadays in the ICU. The
scientific demonstration that no difference exists in
results of using continuous or intermittent administra-
Enteral nutrition in critical patients
tion enables us to choose more freely which ENT form
of delivery will best fit the clinical status of the patient
and the procedures adopted at any given moment regarding its propaedeutics and therapeutic options.
Therefore, if needed, we can decide to submit the
patient to a programmed pause in his diet (intermittent
infusion). During this period a number of activities can
be scheduled which interfere with the infusion, especially for the ICU routine procedures, with no damage
to the enteral nutrition therapy.
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